What is the best management approach for Reiter syndrome (reactive arthritis)?

Management of Reiter Syndrome (Reactive Arthritis)

Initiate high-dose NSAIDs immediately as first-line therapy, with consideration of intra-articular corticosteroid injections for large joint involvement, and treat the underlying infection with doxycycline if genitourinary chlamydial infection is suspected or confirmed. 1

Initial Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis by identifying:

• Asymmetric oligoarthritis (typically large joints like knees, ankles) following a genitourinary or gastrointestinal infection by 1-6 weeks 2, 3
• Classic triad features: conjunctivitis, urethritis, and arthritis (though not all patients present with complete triad) 2, 4
• HLA-B27 positivity in over two-thirds of cases, which predisposes to more severe disease 1, 3
• Negative cultures at time of arthritis presentation, with only serum antibodies detectable 3

Pharmacological Management Algorithm

First-Line Treatment

• High-dose potent NSAIDs are the cornerstone of initial therapy for controlling inflammatory arthritis 1
• Intra-articular corticosteroid injections should be administered for large joint involvement to provide rapid symptom relief 1

Antibiotic Therapy

• Doxycycline or its analogs should be initiated if Chlamydia trachomatis genitourinary infection is suspected or confirmed, as this may shorten the course or abort onset of arthritis 1
• Do NOT use antibiotics for enteric infections with Salmonella or Shigella, as they have not been shown to be effective in these cases 1

Refractory Disease

• If NSAIDs and local corticosteroids fail to control symptoms, consider systemic immunosuppression, though specific guidelines for reactive arthritis are limited in the provided evidence
• Monitor closely for progression to chronic destructive arthritis, which occurs in 15-20% of patients 2, 4

Critical Clinical Pitfalls

HIV Screening is Mandatory

• Reactive arthritis may be the first manifestation of HIV infection, so all patients must be screened 1
• HIV-positive patients have particularly difficult-to-treat disease with worse prognosis 2

Distinguish from Septic Arthritis

• Unlike septic arthritis, reactive arthritis does not present with fever, systemic signs of infection, or monoarthritis 3
• Cultures are negative in reactive arthritis at the time of joint symptoms 3

Extra-Articular Manifestations Require Attention

• Dermatologic: keratoderma blennorrhagicum, circinate balanitis, ulcerative vulvitis, nail changes, oral lesions 2
• Ocular: conjunctivitis and uveitis (may be severe) 2, 3
• Cardiac: involvement can occur and varies in severity 3

Monitoring and Prognosis

• Symptoms may persist for prolonged periods and cause long-term disability in some cases 1
• 15-20% of patients develop severe chronic sequelae, including chronic destructive arthritis 2, 4
• Prompt recognition and early intervention are key to better outcomes with fewer complications 4
• Clinical presentation, severity, and prognosis vary widely among patients 2

Special Populations

• Young men are most commonly affected, though cases occur in women and children 2, 1
• HLA-B27 carriers have increased susceptibility, with only 1-15% of infected individuals developing reactive arthritis 3
• Disease frequency in the United States is estimated at 3.5-5 per 100,000 population 4